Liver lesions

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Liver lesions

Dr. Aftab Qadir

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Benign Liver lesions

• Hemangioma• Focal nodular hyperplasia• Hepatic adenoma• Liver cyst• Liver abscess



Malignant• Hepatocellular carcinoma• Heptoblastoma

Rare malignant:• Fibrosarcoma• Angiosarcoma• Leiomyosarcoma• Lymphoma



Hypervascular lesions

Benign• Heamangioma• Adenoma• FNH

Malignant• HCC• Hypervascular metastasis



Hypovascular lesions

• Hypovascular liver tumors are more common.

• Most hypovascular lesions are metastases.



Multiphasic CT

For detection of liver lesions• Non enhance CT• Arterial phase• Portal venous phase• Delayed



Understanding the phases• Liver has dual blood supply• Normal parenchyma is supplied for 80%

by the portal vein and only for 20% by the hepatic artery

• All liver tumors get 100% of their blood supply from the hepatic artery



Arterial phase • In the arterial phase hypervascular tumors

will enhance via the hepatic artery, when normal liver parenchyma does not yet enhances, because contrast is not yet in the portal venous system.

• Hypervascular tumors will enhance optimally at 35 sec after contrast injection



Portal venous phase• To detect hypovascular tumors • Scanning is at about 75 seconds



Delayed Phase• Begins at about 3-4 minutes after contrast

injection and imaging is best done at 10 minutes• Valuable for washout of contrast(HCC),retention

of contrast(heamangioma),retention of contrast in fibrous tissue (capsule of HCC, central scar of FNH)



Pre contrast Arterial Phase Portal venous phase

Delayed

Hepatocelluar Ca Low attenuation Homogenous enhancement

Washout of lesion

Isodense

Adenoma Low attenuation Homogenous enhancement 85%

Iso or hypodense

Iso or hypodense

Haemangioma Low attenuation Peripheral puddles Partial Fill in Complete fill in

FNH Iso/Low attenuation

Homogenous enhancement

Hypodense Isodense

Metastasis(hypervascular) Low attenuation Homogenous enhancement

Hypodense

Metastasis Low attenuation Hypodense Hypodense

Cyst Low attenuation No enhancement

Abscess Low attenuation may have irregular margins

Transient regional increase enhancement

Ring enhancement

Multiphasic CT of Liver



T1W T2W Gadolinium Hepatocellular Ca

,iso or (fat degeneration) Metastasis Haemanigioma ++ (like CT) Adenoma

often FNH + delayed

MRI of Liver



Hepatocellular Carcinoma• Most common primary malignancy of the

liver• Third most common cause of cancer-

related death• The incidence of HCC is rising, largely

attributed to a rise in hepatitis C infection



Risk factors:• hepatitis B (HBV) infection • hepatitis C (HCV) infection • alcoholism • biliary cirrhosis • food toxins e.g. aflatoxins• congenital biliary atresia• inborn errors of metabolism

haemochromatosis

alpha-1 antitrypsin deficiency

type 1 glycogen storage disease

Wilson disease



Clinical presentation

Presentation is variable may include:• constitutional symptoms• jaundice• portal hypertension from invasion of the portal vein• hepatomegally / mass



• Majority of patient have cirrhosis• More than 80% of patients with HCC have

cirrhosis• May be Focal, multiple or diffusely

infiltrative



Investigation• alpha-fetoprotein (AFP) levels are

elevated in 50-75 % of cases• Radiological investigation including

ultrasound, CT and MRI• Biopsy



Ultrasound• Variable appearance• Small <3cm usually hypoechoic• Larger tumors often are heterogeneous• May invade the portal vein• Most tumors will show central vascularity

on Doppler study

Larger tumors often are heterogeneous



CT• Focal HCC

large usually hypodense mass

may have necrosis / fat / calcification• Multifocal HCC

multiple masses of variable attenuation may also have central hypodense necrotic portions• Diffuse HCC

may be difficult to distinguish from associated cirrhosis



Enhancement pattern

• Transient early arterial enhancement and then washes out



MRIT1(variable)

T1 C+ (Gd)

Enhancement similar to CT

Rim enhancement may persist

T2 –Hyperintense

Post SPIO (Iron oxide) - increases sensitivity in diagnosing small HCC’s

Enhancement similar to CT



Fibrolamellar hepatocellular carcinoma

• Variant of HCC• Younger age group(20-40years)• Not associated with cirrhosis• No association with HCC risk factors• Usually present with constitutional

symptoms• Fibrolamellar carcinomas typically are

single large tumours

Not associated with cirrhosis

Fibrolamellar carcinomas typically are single large tumours



Ultrasound• Usually large heterogeneous

predominantly hyperechoic lesion, calcification may be seen(40%)



CT• Large solitary well circumscribed• Heterogeneous arterial enhancement• 30-40% have central scar• Calcification can be seen on non

enhanced CT



Hepatic metastasis• More common than primary • May be solitary but usually multiple• Majority are hypovascular• Extremely variable appearance on

ultrasound



Hypervascular metastases• Carcinoids• Leiomyosarcomas• Neuroendocrine tumors• Renal carcinomas• Thyroid carcinomas• Choriocarcinomas• Occasionally pancreas, ovary, or breast



UltrasoundHypoechoic metastasis• Lymphoma• Sarcoma• Most adenocarcinoma(breast, lung, pancreas)



Hyperechoic• Colorectal carcinoma and other GIT• Carcinoid, Renal cell carcinoma, islet cell

tumor



Cystic metastasis• Ovarian carcinoma• Cystadenocarcinoma of pancreas• squamous cell carcinoma

Calcified metastasis• Mucinous adenocarcinoma of colon



CT• On unenhanced CT -> Hypodense• On Enhanced CT -> non enhancing

hypodense• The margin of the lesions can vary from

well defined to ill defined• Hyperattenuating lesions are uncommon



MRI• Most metastase are hypointense on T1• Hyperintense on T2



Interactive cases



Liver calcification causes??



Thank you


Liver lesions

Health & Medicine

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